Identification of diabetic complications among minority populations.

OBJECTIVE: In consideration of the increasing prevalence of diabetes, multiple factors related to levels of long-term glycemic control, and complex causes of racial disparities across a variety of chronic conditions, patterns of admissions and complications related to diabetes by ethnicity were explored to develop a more clear understanding of underlying causes of disparities. METHOD: Using the 2003 National Inpatient Sample, we analyzed the correlation between the primary diagnosis and the likelihood that the condition represented poorly controlled diabetes or a diabetes-related complication. RESULTS: Minorities were more likely to be admitted through the emergency department and for a condition directly related to diabetes progression. Further, minorities were more likely to be admitted for acute hyperglycemia and acute hypoglycemia. CONCLUSION: Interventions that address root causes of disparities related to diabetes and other conditions, such as care-seeking behaviors and ease of access to primary care providers, are keys to eliminating ethnic disparities.

Factors underlying racial disparities in hospital care of congestive heart failure.

OBJECTIVE: To examine relationships between race and five aspects of hospital care. METHODS: Cross-sectional data of 373,158 discharges with heart failure in the 1995-1997 National Inpatient Sample were used to measure severity, care-seeking patterns, processes, resource consumption, and outcomes. RESULTS: Compared to White patients, African American and Hispanic patients were more likely to seek care through the emergency department (ED) but less likely to receive clinical procedures or die in the hospital. Interactions of African American race with patient co-morbidity status, admission through the ED, and receipt of intensive services were associated with lower mortality as was interaction between admission to teaching hospitals and Hispanic race. CONCLUSIONS: Lack of access to ambulatory care among minority patients and hospital care via the safety net may contribute to racial discrepancies as a result of healthier patient selection among minority groups.

Disparities in outcomes among patients with stroke associated with insurance status.

BACKGROUND AND PURPOSE: Despite well-documented discrepancies in many clinical conditions across insurance groups, limited research has examined insurance-related disparities for patients with stroke. This study examined the relationship between insurance status and hospital care for patients with stroke. METHODS: Discharges with intracerebral hemorrhage and acute ischemic stroke were abstracted from the 2002 National Inpatient Sample. Neurologic impairment status and mortality were examined. RESULTS: Compared with privately insured patients, uninsured patients had a higher level of neurologic impairment, a longer average length of hospital stay, and higher mortality risk. For patients with intracerebral hemorrhage and acute ischemic stroke, mortality risk of uninsured patients was approximately 24% and 56% higher, respectively, than that of their privately insured peers. CONCLUSIONS: Policy should promote access to outpatient and preventive care for uninsured patients so risk factors such as hypertension can be detected and treated during early, asymptomatic stages. Further research is needed to evaluate the extent to which differences in outcomes are attributable to differences in severity level on admission.

Gender discrepancies in the level of disease progression in hospitalized patients with diabetes.

Diabetes is a widely recognized and common cause of mortality, morbidity, and excess cost in the health care system. Type 2 diabetes is specifically on the rise, particularly in association with the increasing obesity rate. Substantial literature has examined differences in behavior across genders and potential effect on disease. However, based on a literature review, little has been done to evaluate differences in patterns of diabetes related to inpatient care across genders and to link these differences with potential explanations related to differences in care-seeking behavior, treatment compliance, and lifestyle choices. This review and analysis of national inpatient data demonstrates substantial differences associated with gender in patterns of hospital-based care in patients with type 2 diabetes. Men are more likely to be admitted for diabetes-related conditions and to present with blood sugars at extreme levels, including acutely elevated and dangerous blood sugar levels. When considering these findings in conjunction with the existing literature, it can be concluded that these differences are primarily reflective of variances in care-seeking behavior and long-term adherence to prescribed medications. Policies that promote expansion of health care benefits to include coverage for men at risk for type 2 diabetes, aggressive education and treatment programs, and expanded prescription drug coverage are necessary to reduce gender discrepancies in patterns of hospitalization and to improve outcomes.

Care patterns for affective psychosis across diverse ethnicities: exploring potential contributors to complications and emergency room utilization.

OBJECTIVE: To explore associations between access to care and environmental stressors with emergency room admissions; to evaluate patterns of complications across diverse ethnic groups related to affective psychosis. METHODS: Data from the National Inpatient Sample were used to evaluate complications and frequency of hospitalization through the emergency room as a proportion of all hospital admissions for affective psychosis across diverse ethnic groups. Unemployment data, variations of trends of proportions of emergency room admissions after the September 11th tragedy, and ratios of primary care physicians/psychiatrists to the general population were evaluated. RESULTS: Admissions through the emergency room as a percentage of all admissions for affective psychosis decreased from 1995 through 1999 but increased in 2001, showing a potential association with increasing unemployment rates and the September 11th tragedy. Over the same period, relatively higher frequencies of emergency room admissions as a proportion of all hospital admissions among African Americans decreased. No significant differences for complications or emergency room utilization were observed between African Americans and Whites by 2001. During the entire period, frequencies of complications in the Hispanic and Asian populations remained lower than frequencies in both African American and White populations. No associations were found between physician-to-population ratios and utilization of the emergency room. CONCLUSION: Patterns of emergency room utilization and complications in African American and White populations appear to show some association with environmental stressors. Further study is warranted to evaluate protective factors associated with lower risk of complications in both Hispanic and Asian populations.

Barriers of HIPAA regulation to implementation of health services research.

Although many perspectives on the impact of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) on health services research have been wide spread, little empirical evidence has been reported about HIPAA-related barriers during the implementation of research projects. Using three cases of health services research projects, this study examined practical barriers created by HIPAA regulation. During the stage of implementation of the three projects, we experienced some HIPAA-related concerns, previously raised in the field of health services research. We found that technically complicated consent forms and privacy protection forms as well as socially-sensitive clinical conditions make patients less willing to participate in research projects; concerns about safety of patient medical information makes health organizations more hesitant to let researchers have access to the patient's information, especially through electronic transfer; more restrictive IRB processes and challenging patient recruiting processes make health services researchers reluctant to go through the process; and as a result, they may compromise with the scientific soundness of the project. Overall, HIPAA complicates the research process and requires more resources and longer time to conduct research.

Patterns of hospital-based pediatric care across diverse ethnicities: the case of pneumonia.

Few studies have evaluated racial disparities with respect to process and outcome measures for pneumonia. We evaluated disparities with respect to process measures in addition to clinical and financial outcome measures in a pediatric population from 0 to 18 years of age. The data showed that minority populations were admitted at younger ages and were more likely to be admitted through the emergency department than their white counterparts. Substantial variation exists with respect to patterns of care and outcomes for pneumonia in pediatric patients among different ethnic/racial groups. Differences in outcomes may be associated with several factors, including variations in quality of care across different hospital settings, characteristics related to disease severity among different ethnic groups, and other unidentified factors. Further research is needed to clearly define how differences with respect to quality of care, access to care, disease severity, and care-seeking behaviors contribute to differences in outcomes across different ethnic groups.

Racial disparities in the pathogenesis and outcomes for patients with ischemic stroke.

Using the 2000 National Inpatient Sample, this study examined the patterns of disparities regarding acute care outcomes of ischemic stroke among Caucasian, African-American, Hispanic, and Asian/Pacific-Islander patients. The data from 13,316 patients with carotid artery-related stroke and 33,149 patients with cerebral artery occlusion were examined. Although racial disparities associated with carotid artery occlusion and cerebral artery occlusion varied, overall, as compared with Caucasians, minorities suffered greater neurologic impairment and had poorer outcomes. For example, among patients with carotid artery occlusion, 62.5% of Caucasian patients had paralysis, compared with 71.2% of African Americans, 69.1% of Hispanics, and 74.0% of Asian patients. Poorer outcomes among African Americans and Hispanics coexisted with higher frequencies of cerebral artery disease in these populations, suggesting possible etiologic factors related to diabetes and high cholesterol levels. Etiologic factors contributing to disparities in the Asian population remain to be determined.